PT 1
F91.9 UNSPECIFIED DISRUPTIVE, IMPILSE-CONTROL. AND CONDUCT DISORDER
The patient is A 18-Year-old male who came to the clinic with his grandmother. The grandmother stated that when the patient is angry, he yells and uses foul language. He has been unable to control his anger lately. The client has been throwing fits at home and school. He does not like to be held accountable of his actions. The client is alert and oriented. He appears calm, with logical thoughts. He also denies thoughts of hurting self and others. HAS BEEN THROWING FISTS AT HOME AND SCHOOL.
MEDICATIONS: none needed at this time
PLAN:
The therapist prescribed CBT for 3 months. The patient will see a therapist every two weeks. For 3 months. The goal is to help patient increase and practice the ability to manage anger. We will also help client improve his overall mood, and be able to express anger without yelling and using fool language.NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
(include psychiatric ROS rule out)
Past Psychiatric History:
·
General Statement:
·
Caregivers (if applicable):
·
Hospitalizations:
·
Medication trials:
·
Psychotherapy or
Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
·
Current Medications:
·
Allergies:
·
Reproductive Hx:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Differential Diagnoses:
Reflections:
Case Formulation and Treatment Plan:
References
© 2021 Walden University
Page 1 of 3NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Comprehensive Psychiatric Evaluation Template
AND
the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
·
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
·
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5 diagnostic criteria for each differential diagnosis and explain what
DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case
.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment
!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the
initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For examplBack to Week at a Glance
COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
TO PREPARE
· Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
· Select a patient for whom you conducted psychotherapy
for an impulse control or conduct disorder
during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed, and each page must be initialed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of each page that is initialed and signed by your Preceptor. You must submit your note using SafeAssign.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
· Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· Include at least five scholarly resources to support your assessment and diagnostic reasoning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
THE ASSIGNMENT
Present the full complex case study. Be succinct in your presentation, and do
not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
·
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
·
Objective: What observations did you make during
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